[104-10222-10040.pdf — page 77]
IMPORTANT—The filing of this form will completely cancel any Designation of Beneficiary under the Federal Employees’ Group Life Insurance Act you may have previously filed. Be sure to name in this form all persons you wish to designate as beneficiaries of any group life and accidental death insurance payable under that act at your death.## EXAMPLES OF DESIGNATIONS### HOW TO DESIGNATE ONE BENEFICIARY| Type or print first name, middle initial, and last name of each beneficiary | Type or print address of each beneficiary | Relationship | Share to be paid to each beneficiary || --------------------------------------------------------------------------- | ----------------------------------------- | ------------ | ------------------------------------ || Mary E. Brown*                                                              | 214 Central Avenue, Muncie, Ind.          | Niece        | All                                  |### HOW TO DESIGNATE MORE THAN ONE BENEFICIARY| Type or print first name, middle initial, and last nama of each beneficiary | Type or print address of each beneficiary | Relationship | Share to be paid to each beneficiary || --------------------------------------------------------------------------- | ----------------------------------------- | ------------ | ------------------------------------ || Alice M. Long                                                               | 509 Canal Street, Red Bank, N. J.         | Aunt         | One-fourth                           || Joseph P. Brady                                                             | 360 Williams Street, Red Bank, N. J.      | Nephew       | One-fourth                           || Catherine L. Rowe                                                           | 792 Broadway, Whiting, Ind.               | Mother       | One-half                             |### HOW TO DESIGNATE A CONTINGENT BENEFICIARY| pe or print first name, odile initiel, and lost name of each bensñetary | Type or print adhirese of each beneficiary | Relationship | Share to be paid to sach LoneSciary || ----------------------------------------------------------------------- | ------------------------------------------ | ------------ | ----------------------------------- || John M. Farrish, ir living                                              | 810 Most 180th Street, Non Tork, N. Y.     | Father       | All                                 || Otherwise to: Susan A. Parrish                                          | 810 West 180th Street, Now York, N. Y.     | Sister       | All                                 |### HOW TO CANCEL A DESIGNATION OF BENEFICIARY SO THAT AMOUNT DUE WILL BE PAYABLE AS PROVIDED IN THE LAW| Type or print first name, middle initial, and last name of cach beneficiary | Type of print midreas of each beneficiary | Relationship | Share to he pas to ench beneficiary || --------------------------------------------------------------------------- | ----------------------------------------- | ------------ | ----------------------------------- || Cancel prior designations                                                   |                                           |              |                                     |*Do not write name as M. E. Brown or as Mrs. John H. Brown.Be sure that she shares to be paid to the several beneficiaries not up to 100 percent.